THE EUROPEAN PEER SUPPORT PROJECT:
PEER SUPPORT AS A METHOD
FOR AIDS PREVENTION IN IDU COMMUNITIES
The European Peer Support Project
`Encouragement, development and support of AIDS prevention
by peer support in intravenous drug user communities'
is supported by the
Commission of the European Communities
Utrecht, July 1994
Project `Aids en Druggebruik'
3500 AS Utrecht
tel:* 31 - 30 - 34 13 00
fax:* 31 - 30 - 31 63 62
In recent years there has been a growing acknowledgement that peer support and peer education can be effective in reducing risk behaviour in IDU communities. Peer support or peer education projects have been developed, in different European countries, both by professionals and self-organisations (National Committee on AIDS Control, 1993). Efforts have been made, too, to initiate and support drug user self-help groups and self-organisations especially in the field of AIDS prevention in intravenous drug user (IDU) communities. One reason for this has been the finding that AIDS prevention by regular (drug aid) services has not been a complete success. Still, there are drug users who lack information, who simply are not reached by drug aid programs or who are not reached because of - among other things - their feelings of distrust. These feelings of distrust are one reason why peer support is considered a worthwhile method to get in contact with drug users who are not reached by drug aid institutions.
Experience confirms that peer education and peer support do contribute to adequate AIDS prevention with drug users (Friedman et. al., 1987). Inside information, knowledge from personal experience and trust are important items in this respect. AIDS prevention in the sense of discussing personal business such as drug use and sex requires trust. Experience furthermore underlines that social influence on drug users' attitude towards safer behaviour and a growing self-efficacy through role modelling are the most important features of peer education/peer support. This implies that providing social information is more important than offering mere facts. The fact that peers are familiar with the group norms and that they are easier to trust for drug users also helps to get reliable information about risk behaviour. Those elements of factual knowledge which have proved to be important have to do with details (e.g. infection risk by sharing the spoon or the filter).
Although the concepts of peer support and peer education have a lot in common, there are important differences, too. One is that peer education implies and emphasises the inequality of the educator and the educated. In an AIDS prevention project for drug users, the task of a peer educator would be to teach other drug users the rules of safer use and safer sex. With the concept of peer support, however, the idea of mutual support is prevailing. The emphasis is more on shared experiences and equality. In addition to this, support is a broader concept than education, since it does not only mean influencing other drug users towards safer use and safer sex. It may also imply creating better conditions for safer behaviour, for instance by distributing syringes and needles.
2 PEER SUPPORT PROJECTS IN THE NETHERLANDS
Because of the equality-element and the wider range of the concept, peer support fits in well with the work of drug user self-organisations. In the Netherlands, autonomous drug user self-organisations have in fact laid the basis for the involvement of drug users in AIDS prevention. Hence, peer support has always been the prevailing phenomenon there. The growing recognition of the contribution of drug user self-organisations to the approach of the drug and AIDS problem has, on the one hand, resulted in financial support for some of their activities by the Ministry or by local authorities. On the other hand, in recent years different peer support and peer education projects have been started or supported by professional organisations - often financed by the Ministry - in order to assess the merits of this approach.
To make the experience gained accessible to other organisations, NIAD has been asked to describe this approach and make a global evaluation of three of these projects (Trautmann 1992; Beer and Trautmann 1993; Trautmann 1993). This information has been circulated to drug aid services as well as to self-organisations through the national network of the Project `AIDS and Drug Use' of the NIAD. This work and some requests for information from organisations in other countries gave us the idea to make the information available to a broader public. Thus, a plan has been developed to carry out a peer support project in six countries of the European Community. To realise this plan financial support has been applied for and obtained at the Commission of the European Communities.
3 THE EUROPEAN PEER SUPPORT PROJECT
In October 1993 the project `Encouragement, Development and Support of AIDS Prevention by Peer Support in Intravenous Drug User Communities' was started. Main aim of this project was to encourage, develop and support professional drug aid services and drug user self-organisations and networks to start or extend peer support strategies especially in the field of AIDS prevention. The emphasis of this project lay - once again - not so much on peer education but on peer support.
The basic elements of this project were:
· to design guidelines for training courses for (injecting) drug users by using the expertise gained in different countries aiming at a snowball effect;
· to organise, as a result of this, training courses on location for key persons - drug users and professionals - in six countries of the EU (England, France, Germany, Italy, The Netherlands and Spain);
· to offer consultation to local organisations in the participating countries, as a follow-up of the training courses or at the request of organisations not involved in the training courses;
· to draw up a training manual - in the languages of the six countries involved - for professionals as well as self-organisations.
3.1 The Contents of the Training Courses and the Manual
The training courses as well as the manual (Trautmann and Barendregt 1994) concentrated on three basic issues:
1 the safer sex and safer use message (risks of infection, how to inject as safely as possible, alternatives for shooting up, how to use a condom, etc.);
2 methods (outreach work, training course (models) for and by drug users, etc.),
3 organisation (how to set up a self-organisation, how to find professional support, how to set up a local network, etc.).
3.1.1 The Content of the Message
Of the subject of the message, of course one part is factual knowledge about the technical aspects of safer use and safer sex, like infection risks, etc. It is evident that a detailed injection instruction as well as an instruction for the use of condoms are essential here. Other important issues are:
· alternatives for injecting drugs (like chasing the dragon),
· cleaning syringes and needles,
· information about the HIV test, etc.
However, the aim of a training course is not primarily to `teach' the rules of safer sex and safer use to drug users but to achieve a spin off effect by peer support. The target group of such a course - and the manual - are key persons in the drug scene, i.e. drug users who play the role of peer leader, or professionals who want to stimulate peer support. This implicates that besides transferring knowledge about safer sex and safer use important subjects are:
· methods of delivering the message
· organisational skills (making a plan of action, etc.).
Furthermore, the content of the message is not restricted to factual knowledge. Up to a certain degree, factual knowledge is even the least important issue. At least in Northwest Europe, drug users generally know quite well what the risks are and how they can be avoided. Yet, this does not mean that their behaviour is consistent with this knowledge. And this is the point which deserves quite some attention. It implicates that it is vital to pay attention to social information regarding attitude, self-efficacy and the social standards of drug users. As already stated, it is exactly in this field that peer support has its advantages. Peer support is especially effective because it is offering a role model to identify with. It is not only mutual support that effectuates safer behaviour but also peer pressure to adapt to the norms or rules of safer sex and safer use. One important issue here is changing or developing habits or rituals towards safer behaviour, e.g.:
· always have a clean needle and syringe with you,
· always take care of getting a clean needle and syringe before buying dope, etc.
However, these habits can and will only be developed when having needles and syringes on you will not be used against you by police and justice.
3.1.2 Methods of Delivery
In general, within the different peer support projects two approaches were used, one for the unstructured setting of the streets, outreach work, and another for more structured, indoor training courses (Kaplan et. al., 1993; Penners 1992; Trautmann 1992; Beer and Trautmann 1993). In the training courses as well as in the manual the focus has been on these two approaches.
The unstructured AIDS prevention approach of the streets is very similar to outreach work by professional street workers. This approach is essential for making contact, for reaching the `unreached'. In general this is a much easier job for drug users than for professionals. They already know a lot of their peers, they are familiar with the scene codes, they usually do not have to deal with the same suspicion as professionals, etc.
Building contacts can be facilitated by handing out something. Information materials, especially if they are lifestyle-oriented can be effective here, as has been demonstrated by the work of Mainline in The Netherlands. Among other things Mainline is the publisher of a professionally designed magazine in which the AIDS prevention message and general information on health for drug users is incorporated in a 'life-style' formula. Thus, Mainline features articles on street life, sex work, falling in love, services for drug users, a comic, the different ways of using drugs, life stories, etc. Nearly all the articles are based on and/or reflect the experiences of drug users. The magazine is distributed person-to-person on the streets. This is where contacts are built to talk about health and health problems, or about confidential matters such as safer sex and safer use, where exchange of information takes place. The people from Mainline not only publish information for drug users but they also get information from them e.g. to use in articles for the magazine (Boomen 1993).
It may be clear from this example, that outreach work is also an important means for getting the message across. Discussing personal and touchy matters like using drugs and having sex, is often easier in one's own familiar environment than on someone else's territory, like in the premises of a drug service.
Whereas AIDS prevention through outreach work normally is confined to what could be called `spontaneous counselling' - short, incidental talks about relatively small bits of the AIDS prevention message - training courses offer the opportunity to deal with issues longer and more intense. In fact, these two elements may supplement each other quite well. A combination of outreach work and training session(s) seems therefore to be especially effective. The intensive introduction to AIDS prevention by a one or two session training course may have more impact if it is supported by short, incidental talks. These talks serve as reminders, focusing one more time attention on the subject.
In these training courses, once again, the emphasis lies not only on knowledge about safer use and safer sex but also on attitude, social standards and self-efficacy (Dam 1991; Trautmann 1992). To ensure that more than factual knowledge only is transferred, the interactive character of the training session is important. Participants should not be taught but stimulated or even provoked to take part in the discussions. Therefore, exercises based on active participation have been chosen. One example is the safer use instruction where we ask one participant to show how he or she is preparing and taking a shot. Our experience is that this provokes active involvement of other participants, who may observe the demonstrator is making mistakes, or that they prefer it done differently, etc. The role of the trainer is basically to guide the discussion and to make sure that no inaccurate information is provided and nothing is missed.
3.1.3 Organisational Aspects of Peer Support
The organisation of peer support can be divided into two basic structures:
1. peer support through drug users self-organisations such as interest or self-help groups, or,
2. peer support through professional organisations, for instance a drug aid agency or a health service.
The reality of most peer support projects, however, has been a mix of these two. In the manual the organisational aspects are grouped under four headings:
· options to establish the organisational basis,
· relevant organisational aspects and considerations for peer support in general,
· relevant organisational aspects and considerations for peer support (primarily) based on a self-organisation, and
· relevant organisational aspects and considerations for peer support (primarily) based on a professional organisation.
220.127.116.11 Establishing the Organisational Basis
Experience shows that there are different ways to work out the concept of peer support and there are, of course, a number of aspects which need thorough discussion before starting a new project. There are some basic choices to be made, such as:
· the choice whether peer support should be carried out by a more or less autonomous self-organisation or be embedded in a professional organisation;
· the decision to pay for the work or not;
· the question whether to include only active drug users or substituted or even ex users, too;
· the decision to focus exclusively on AIDS prevention or not.
18.104.22.168 General Organisational Aspects
Here, the focus is on how to organise peer support, concentrating on organisational aspects of peer support important both to self-organisations and professional organisations. The following - internal and external - affairs are dealt with:
· collecting information, making an inventory of the living situation of the target group(s), etc.
· (based on this information) defining aims, tasks, target group(s) and approach
· the position of the `peer supporters' (employees, free lance workers, volunteers)
· selection of the workers (profile, job description, etc.)
· training and personal or other support of the workers
· evaluation (to establish the range of the project, process and effect evaluation, etc.)
· establish the position of the project in the field of drug and AIDS prevention and/or care services
· public relations (promotion of the project, getting and keeping public attention for the project)
· cooperation with other organisations
22.214.171.124 Peer Support through Self-organisations
There are similarities and differences in the way either self-organisations or professional organisations organise peer support. When starting and running a peer support initiative as a self-organisation some specific organisational aspects need to be clarified. The European Peer Support Project has been focused on the interest group-model. The following matters are dealt with in the manual:
· definition of the interests (which and whose interests should be represented)
· establishing an organisation (getting and keeping drug users involved, choosing an organisation form, structure of the organisation, finding (professional) support, etc.)
126.96.36.199 Peer Support based on Professional Organisations
Peer support based on professional organisations usually is developed by and embedded in an already existing organisation. It is for instance quite common that peer support is chosen by a professional drug aid service as an approach to reach the `unreached' because professional drug aid workers have not succeeded in doing so. Due to this, the situation is quite different from the usual starting point of a self-organisation. It is not necessary to build up the organisation from the start. This is, however, not just an advantage. It may also cause problems because sometimes it is harder to change or to adapt an organisation than to build one.
Here, the focus is on some characteristic issues of peer support based on professional organisations, such as:
· different models (create a separate team for peer support or add drug users to an already existing team of professionals, etc.)
· organisational preconditions (support of `peer supporters' and professionals to ensure fruitful cooperation, organisational adaptations regarding e.g. office hours and the influence of drug users on the organisation's policy, introducing the employed drug users to cooperating organisations).
4 Training Course and Manual in the Six Countries
To ensure that this European project would meet the actual needs in the different countries, a steering committee was installed. The members of this committee were experts from the participating countries, who did not only provide necessary information about the specific local/regional/national situation, but also played an important role in choosing the city or region in which the training courses were held. Finally, they were responsible for the contacts with relevant persons and organisations, and they helped to select suitable trainers.
Important criteria for the selection of the city or region in which the training courses were held were:
· there is no peer support initiative in the field of AIDS prevention,
· there is no well functioning drug user self-organisation,
· a minimal level of possible support - either by a professional (drug) service (the policy of which should be based on the concept of harm reduction) or/and by active drug users - is guaranteed. This is a precondition for the possible future development of a peer support initiative.
The training courses (two or three days, four to six hours per day) were held in the period from March to May 1994. One training course was organised in each of the six countries. The actual contents of each course and their target groups were established in cooperation with local experts (professionals and drug users), adjusted to local conditions. Accordingly each course was preceded by a preparatory visit to set up the programme and arrange the necessary matters such as venue, choice of the trainer(s), training of the trainer(s), selection of the participants, etc. Another important element of the preparatory visit was public relations, i.e. to draw attention to peer support as contributing to harm reduction. Therefore contacts were made with local or regional organisations and services, talks were arranged with politicians and the media, etc.
Consequently, the exact programme of the training courses varied from country to country, due to the local situation. In The Netherlands the choice was made to held a `nation-wide' training course, embedded in the development of a network of local drug user self-organisations. In the other countries the courses were organised on a local or regional level, in order to facilitate follow-up activities. In Spain (Madrid) and Italy (Verona) the choice was made to hold a training course in which both workers and drug users participate. In this way it was tried to make a start with involving drug users in AIDS prevention activities. The emphasis in the training courses was on stimulating drug users to organise themselves and to professionals to support them in doing so. In France we chose to focus on the work of two cooperating general practitioners in Vitry sur Seine, a suburb south of Paris. These two doctors are providing substitution treatment for some of their drug using patients. In this part of Paris seroprevalence is very high and there are nearly no services for drug users. In the United Kingdom (Oxford) the emphasis was on people who experiment with drug use. The target group were people from within the rave scene, some of them belonging to the so-called Convoy, people travelling around the country. In Germany (Nürnberg) the training course was organised in cooperation with the local drug service MUDRA. The target group were drug users from the local street scene who were regarded as key persons. Beside drug users, three professionals (one outreach worker and two social workers from the MUDRA Contact Cafe) participated, to create a basis for follow-up professional support.
A preliminary manual, in which the experiences with peer support in different countries were incorporated, served as the basis of the training courses. This basic material was used to draw up the actual training course with the help of people from local/regional organisations and the selected trainers.
After the training course participants (and trainers) were asked to fill in a questionnaire to evaluate (structure and contents of) the training course. For two months after the training course local developments were monitored and, if necessary, supported by consultancy. After these two months participants and workers from the organisations involved were interviewed about possible follow-up activities.
The definitive manual (Trautmann and Barendregt 1994) and the final report will be available by the end of September.
Beer, M. de, Trautmann, F., Het Modelproject 'Aidspreventie voor en door prostituées': 'peer support als methode'. Utrecht (NIAD) 1993.
Boomen, I'm looking for my Mainline, in: National Committee on AIDS Control, Encouraging peer support for risk reduction among injecting drug users. Amsterdam/Utrecht (NCAB/NIAD) 1993, p. 32- 38.
Dam, T. van, Het verloop van de training. Deventer, 8 april 1991.
Friedman, S.R., Des Jarlais, D.C., Sotheran, J.L., Garber, J., Cohen, H., Smith, D., AIDS and Self-Organisation among Intravenous Drug Users, in: The International Journal of the Addictions, jrg. 22, nr. 3, 1987, p. 201-219.
Friedman, S., Going beyond education to mobilizing subcultural change, in: National Committee on AIDS Control, Encouraging peer support for risk reduction among injecting drug users. Amster- dam/Utrecht (NCAB/NIAD) 1993, p. 4-13.
Kaplan, Ch., Mercera, B., Meulders, W.A.J., Penners, G., Bieleman, B., The `Boule de Neige' Project: Lowering the Treshold for AIDS Prevention among Injecting Drug Users, in: The International Journal on Drug Policy, Vol 3, No. 4, 1992, p. 170-175.
Middelthon, A.-L., Drug users as partners in HIV-preventive work, in: National Committee on AIDS Control, Encouraging peer support for risk reduction among injecting drug users. Amsterdam/Utrecht (NCAB/NIAD) 1993, p. 14-22.
National Committee on AIDS Control, Encouraging peer support for risk reduction among injecting drug users. Amsterdam/Utrecht (NCAB/NIAD) 1993.
Penners, G., Evaluatie-rapport Aidspreventie-project "Boule de Neige", Euregio. Maastricht (CAD Limburg) 1992.
Trautmann, F., Het Aidspreventie-project 'No-Risk': 'peer support' als methode. Utrecht (NIAD) 1992.
Trautmann, F., Procesevaluatie van het MDHG-Project 'Drugs, Gezondheid en AIDS' (concept, eerste bevindingen t.b.v. subsidie- aanvraag Landelijk Steunpunt Druggebruikers). Utrecht (NIAD) 1993.
Trautmann, F., Barendregt, C., The European Peer Support Manual - peer support as a method for aids prevention in idu communities. Utrecht (NIAD) 1994.
Franz Trautmann, staff member of NIAD, Project `AIDS and Drug Use', worked for different drug aid services and has been involved in the work of various drug user interest groups.